Current AMA Policies: Resident Work Hours/Conditions

Council on Medical Education Report 9, A-02: Resident Physician Working Conditions
Council on Medical Education Report 8, A-02: The Effect of Nursing Shortage on Medical Education
H-310.928 Resident/Fellow Work and Learning Environment
H-310.979 Resident Physician Working Hours and Supervision
H-310.957 Resident Working Conditions Reform Update
H-310.958 Graduate Medical Education Reform Legislation
H-310.961 Residency/Fellowship Working Conditions and Supervision
H-310.963 Residency/Fellowship Working Hours and Supervision
H-310.975 Revision of the ACGME Essentials of Accredited Residencies in Graduate Medical Education
H-310.999 Guidelines for Housestaff Contracts or Agreements

H-310.927 Council on Medical Education Report 9 (A-02): Resident Physician Working Conditions
(1) That our American Medical Association adopt the following definitions for resident physician education:
"Total duty hours" represents those scheduled hours of activity associated with a residency program and include: a) scheduled time providing direct patient care or supervised patient care that contributes to the ability of the resident physician to meet educational goals and objectives; b) scheduled time to participate in formal educational activities, c) scheduled time providing administrative and patient care services of limited or no educational value, and d) time needed to transfer the care of patients.
"Organized educational activities" are of two types: (a) "Formal educational activities" include scheduled educational programs such as conferences, seminars, and grand rounds and (b) "Patient care educational activities" include individualized instruction with a more senior resident or attending physician and teaching rounds with an attending physician. (New HOD Policy)

(2) That resident physician total duty hours must not exceed 80 hours per week, averaged over a two-week period and that our AMA work with GME accrediting bodies to determine if an increase of 5% may be appropriate for some training programs. (New HOD Policy)

(3) That workdays that exceed 12 hours are defined as on-call. (New HOD Policy)

(4) That scheduled on-call assignments should not exceed 24 hours. Residents may remain on-duty for up to 30 hours to complete the transfer of care, patient follow-up, and education; however, residents may not be assigned new patients, cross-coverage of other providers’ patients, or continuity clinic during that time. (New HOD Policy)

(5) That on-call be no more frequent than every third night and there be at least one consecutive 24-hour duty-free period every seven days both averaged over a two-week period. (New HOD Policy)

(6) That on-call from home be counted in the calculation of total duty hours and on-call frequency if the resident physician can routinely expect to get less than eight hours of sleep. (New HOD Policy)

(7) That there should be a duty-free interval of at least 10 hours prior to returning to duty. (New HOD Policy)

(8) That limits on total duty hours must not adversely impact resident physician participation in the organized educational activities of the residency program. Formal educational activities must be scheduled and available within total duty hour limits for all resident physicians for at least eight hours per week averaged over a two-week period. (New HOD Policy)

(9) That scheduled time providing patient care services of limited or no educational value be minimized. (New HOD Policy)

(10) That program directors should establish guidelines for scheduled work outside of the residency program, such as moonlighting, and must approve and monitor that work. (New HOD Policy)

(11) That as continued evidence is developed and collected regarding resident work hours, patient safety, resident well-being, and resident education, resident physician total duty hours be reassessed. (Directive to take action)

(12) That our AMA: a) strongly encourage the Accreditation Council for Graduate Medical Education (ACGME) to vigorously enforce the common accreditation standards adopted by their Board of Directors on June 11, 2002 regarding resident duty hours and b) that the ACGME be requested to provide the AMA with a report on the number of programs by specialty that were required to provide immediate progress reports to Residency Review Committees and the Institutional Review Committee as well as the number of programs for which resident surveys and focused follow-up visits were conducted, beginning with the period of July 1, 2001-June 30, 2002 and then on an annual basis. (Directive to Take Action)

D-360.996 The Effect of Nursing Shortage on Medical Education
(1) That our American Medical Association encourage accrediting bodies for medical education programs (the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education) to rigorously enforce (or develop and enforce) standards to ensure that the educational experience of trainees is not compromised by inadequate staffing levels of nursing and ancillary personnel in teaching hospitals. (Directive to Take Action)

(2) That our AMA, using data from internal and external sources, monitor the national and regional availability of nursing and ancillary personnel and the mechanisms used by hospitals and other health care institutions to provide staff coverage. (Directive to Take Action)

(3) That our AMA, through the Medical Schools, Medical Student, and Resident and Fellow Sections, collect data on how the availability of nursing and ancillary personnel is affecting the educational experiences of physicians-in-training. (Directive to Take Action)

(4) That our AMA support increased funding for basic nursing education. This funding should come from new monies, not from funds currently devoted to medical student or resident physician education. (Directive to Take Action)

(5) That our American Medical Association monitor efforts to increase recruitment and retention of individuals in nursing education and practice and the implications of basic nurse staffing levels on patient safety and access to care.

H-310.928 Resident/Fellow Work and Learning Environment
Our AMA may draft original, modify existing, or oppose legislation and pursue any regulatory or administrative strategies when dealing with resident work hours and conditions .

H-310.979 Resident Physician Working Hours and Supervision
(1) The AMA supports the following principles regarding the supervision of residents and the avoidance of the harmful effects of excessive fatigue and stress: (a) Exemplary patient care is a vital component for any program of graduate medical education. Graduate medical education enhances the quality of patient care in the institution sponsoring an accredited residency program. Graduate medical education must never compromise the quality of patient care. (b) Graduate medical education is a required and integral component of the continuum of medical education and is necessary to prepare physicians for the practice of medicine. Graduate medical education, while emphasizing the care of patients, must include formal and informal education, the study of medical literature and may include experience in research. (c) Institutions sponsoring residency programs and the director of each program must assure the highest quality of care for patients and the attainment of the program's educational objectives for the residents. (d) Institutional commitment to graduate medical education must be evidenced by compliance with Section 5.1.3. of the General Requirements as contained in the Essentials of Accredited Residencies in Graduate Medical Education, which states: "There must be institutional and program policies and procedures that ensure that all residents are supervised in carrying out their patient care responsibilities. The level and method of supervision must be consistent with the Special Requirements for each program." (e) The program director must be responsible for the evaluation of the progress of each resident and for the level of responsibility for the care of patients that may be safely delegated to the resident. (f) Each patient's attending physician must decide, within guidelines established by the program director, the extent to which responsibility may be delegated to the resident, and the appropriate degree of supervision of the resident's participation in the care of the patient. The attending physician, or designate, must be available to the resident for consultation at all times. (g) The program director, in cooperation with the institution, is responsible for maintaining work schedules for each resident based on the intensity and variability of assignments in conformity with Residency Review Committee (RRC) recommendations, and in compliance with the applicable General and Special Requirements of the Accreditation Council for Graduate Medical Education (ACGME). (h) The program director, with institutional support, must assure for each resident effective counseling as stated in Section 5.1.4. of the General Requirements: "Counseling: Graduate medical education places increasing responsibility on residents and requires sustained intellectual and physical effort. For some, these demands will, at times, cause physical or emotional stress. Institutional awareness, empathy, and responsiveness towards these problems are vital to the educational process. Program directors and teaching staff should be sensitive to the need for the timely provision of counseling and psychological support services to residents." (i) The program director, with institutional support, must provide effective support systems; residents should not be required to provide patient care services that can be provided by ancillary personnel. Thus, the educational mission must not be compromised by a routine reliance on resident physicians to fulfill institutional service obligations, such as but not limited to IV services, phlebotomy services and messenger transport services, which can and should be provided by ancillary staff to meet reasonable and expected demands. (j) Is neither feasible nor desirable to develop universally applicable and precise requirements for either the supervision of residents or the maximum time that they are assigned to direct patient care. Because the number of patients, the intensity of illness, and the hospital support services vary among medical specialties, the RRC for each medical specialty must define these requirements for residents in the graduate medical education programs which they accredit. (k) Individual resident compensation and benefits must not be compromised or decreased as a result of these recommended changes in the graduate medical education system. (2) These problems should be addressed within the present system of graduate medical education, without regulation by agencies of government. (CME Rep. C, I-87; Modified: Sunset Report, I-97

H-310.957 Resident Working Conditions Reform Update
(1) The AMA supports the following new language pertaining to resident work hours and environment for the "General Requirements" of the "Essentials of Accredited Residencies in Graduate Medical Education": Each residency program must establish formal policies governing resident duty hours and working environment that are optimal for both resident education and the care of patients. (a) Special requirements relating to duty hours and on-call schedules shall be based on an educational rationale and patient need, including continuity of care. (b) The educational goals of the program and learning objectives of residents must not be compromised by excessive reliance on residents to fulfill institutional service obligations. Duty hours, however, must reflect the fact that responsibilities for continuing patient care are not automatically discharged at specific times. Programs must ensure that residents are provided backup support when patient care responsibilities are especially difficult or prolonged. (c) Resident duty hours and on-call schedules must not be excessive. The structuring of duty hours and on-call schedules must focus on the needs of the patient, continuity of care, and the educational needs of the resident. Duty hours must be consistent with the General and Special Requirements that apply to each program. Detailed structuring of resident service is an integral part of the approval process and therefore close adherence to the General and Special Requirements is essential to program accreditation. (2) The AMA supports the following proposed revision of the "Special Requirements" for surgery: It is desirable that residents' work schedule be designed so that on the average, excluding exceptional patient care needs, residents have at least one day out of seven free of routine responsibilities and be on-call in the hospital no more often than every third night. The ratio of hours worked and on-call time will vary, particularly at the senior levels, and therefore necessitates flexibility. (BOT Rep. YY, I-91)

H-310.958 Graduate Medical Education Reform Legislation
The AMA will defer drafting of model state legislation as called for in Resolution 239 (A-91) in order to allow sufficient time to determine whether negotiations among the appropriate parties will be successful and thereby eliminate the need for such legislation. Should it become apparent that the negotiations do not succeed, the AMA will proceed to draft and support appropriate model state legislation on the issue of resident work hours. (BOT Rep. WW, I-91)

H-310.961 Residency/Fellowship Working Conditions and Supervision
(1) The AMA will continue to work closely with the parties involved in the accreditation of graduate medical education programs to reaffirm the AMA's position on resident working conditions and supervision, to further clarify the various concerns related to resident working conditions, and to explain why specific language is essential to the general issue of working conditions. (2) The AMA will seek a meeting with the Resident Review Committee for Surgery and representatives of the American Board of Surgery and the AMA Resident Physicians Section to discuss resident working hours and conditions. (3) Further actions by the House of Delegates will be considered after a careful review of the General Essentials adopted by the Accreditation Council for Graduate Medical Education during its meeting in June 1991 and of a progress report on the Special Requirements adopted by Residency Review Committees and the ACGME, and an updated report incorporating the results of the AMA commissioned survey of residents' attitudes on working conditions to be submitted for consideration by the House of Delegates at the 1991 Interim Meeting. (BOT Rep. KKK, A-91)

H-310.963 Residency/Fellowship Working Hours and Supervision
It is the policy of the AMA (1) to continue to work with the Accreditation Council for Graduate Medical Education to implement AMA policy for residency work hours reform; and (2) to use existing policy as a guideline in working with state medical societies to obtain modification, if needed, of pending and future legislation on total residency work hours, conditions and supervision. (Sub. Res. 191, I-90)

H-310.975 Revision of the ACGME Essentials of Accredited Residencies in Graduate Medical Education
The AMA advocates working through state medical societies to inform state legislatures and state departments of health of the AMA's role and progress toward the development of Accreditation Council for Graduate Medical Education policy and Residency Review Committee requirements on resident physician work hours and supervision. (Res. 113, I-88; Reaffirmed: Sunset Report, I-98)

H-310.999 Guidelines for Housestaff Contracts or Agreements
The "Essentials of Approved Residencies, " approved by the House of Delegates in 1970, includes a section on relationships of housestaff and institutions. The following outline is intended to promote additional guidance to all parties in establishing the conditions under which house officers learn and provide services to patients.

Training programs have been central to the process of graduate medical education which has produced a high level of medical competence in the United States. The American Medical Association recognizes that the integrity of these programs is a primary objective in achieving the best possible care of the patient. It is, therefore, incumbent upon members of the housestaff and the institutions in which they are being trained to be aware of the parameters and responsibilities applicable to their training programs. In the absence of such awareness, unreasonable expectations may arise to threaten the harmony between hospital and housestaff in the performance of their joint mission.

It should be emphasized that these guidelines are not intended as a fixed formula. Guidelines that seek to cover public, voluntary and proprietary hospitals necessarily entail so many variables from training institution to training institution that no single form of contract or agreement would be universally applicable. This set of guidelines has, therefore, been developed to cover the more significant substantive provisions of a housestaff contract or agreement.

The subjects included in the Guidelines are not intended to be the only subjects important or appropriate for a contract or agreement. Moreover, the definition of the respective responsibilities, rights and obligations of the parties involved can assume various forms: individual contracts or agreements, group contracts or agreements, or as a part of the rules of government of the institution. II. Proposed Terms and Conditions A. Parties to the Contract or Agreement (1) Contracts or agreements may be formed between individuals or groups, and institutions. Such a group might be a housestaff organization. (2) The two parties to an agreement or contract may be a single institution or a group of institutions, and an individual member of the housestaff, an informal group of the housestaff, or a formally constituted group or association of the housestaff, as determined by the housestaff organization. B. General Principles (1) Contracts or agreements are legal documents and must conform to the laws, rules, and regulation to which the institutions are subject. Position, salary and all other benefits should remain in effect insofar as possible without regard to rotational assignments even when the member of the housestaff is away from the parent institution. Exceptions required by law or regulations should be clearly delineated to the house officer at the time of the appointment. Changes in the number of positions in each year of a training program should be made so as not to affect adversely persons already in, or accepted in, that program. The agreement should provide fair and equitable conditions of employment for all those performing the duties of interns, residents and fellows. When a general contract or agreement is in effect between an association and an institution, individual contracts or agreements should be consistent. (2) Adequate prior notification of either party's intent not to review the contract or agreement should be required, and the date of such notification should be included in the contract or agreement. (3) The institution and the individual members of the housestaff must accept and recognize the right of the housestaff to determine the means by which the housestaff may organize its affairs, and both parties should abide by that determination; provided that the inherent right of a member of the housestaff to contract and negotiate freely with the institution, individually or collectively, for terms and conditions of employment and training should not be denied or infringed. No contract should require or prescribe that members of the housestaff shall or shall not be members of an association or union. C. Obligation of the Housestaff (1) Members of the housestaff agree to fulfill the educational requirements of the graduate training programs, and accept the obligation to use their efforts to provide safe, effective and compassionate patient care as assigned or required under the circumstances as delineated in the ACGME "Essentials of Approved Residencies" and previously approved standards of the AMA Council on Medical Education. (2) Members of the housestaff should comply with the laws, regulations, and policies to which the institution is subject. D. Obligation of the Institution (1) The institution agrees to provide an educational program that meets the standards of the ACGME "Essentials of Approved Residencies." (2) The institution agrees to maintain continuously its staff and its facilities in compliance with all of the standards in the ACGME "Essentials of Approved Residencies." E. Salary for Housestaff (1) The salary to be paid and the frequency of payment should be specified. The salary schedule should be published. The basis for increments and the time of the increments should be specified. (2) In determining the salary level of a member of the housestaff, prior educational experience should be considered, and a determination made as to whether credit should be given. (3) The responsibilities of senior residents should be recognized in salary differentials. F. Hours of WorkThere should be recognition of the fact that long duty hours extending over an unreasonably long period of time or onerous on-call schedules are not consistent with the primary objective of education or the efficient delivery of optimal patient care. The institution should commit itself to fair scheduling of duty time for all members of the housestaff, including the provision of adequate off-duty hours. G. Off-Duty Activities The contract or agreement should provide that a member of the housestaff is free to use his off-duty hours as he sees fit, including engaging in outside employment if permitted by the terms of the original contract or agreement, so long as such activity does not interfere with his obligations to the institution or to the effectiveness of the educational program to which he has been appointed. H. Vacation and Leave The AMA encourages residency programs across the country to permit and schedule off-duty time separate from personal vacation time to enable residents to attend educational and/or organized medicine conferences. The amount of vacation, sick leave, and educational leave to which each member of the housestaff is entitled should be specified. Vacations should be expressed in terms of customary working days as defined by the institution. If vacations may be taken only at certain times of the year, this restriction should be stated. Any requirements for scheduling vacation time should also be stated. Provisions may also cover leaves for maternity, paternity, bereavement, military duty, examinations and preparations therefor, and educational conferences. Reimbursement for tuition and expenses incurred at educational conferences should be considered. The agreement should set forth any progressive increases in the amount of time allowed for vacation, sick leave, and educational leave. Educational leave should not be deducted from vacation time. I. Insurance Benefits Insurance benefits should be set forth with particularity and should be tailored to the specific needs of the housestaff. Some of the more common insurance benefit provisions are (1) hospitalization and basic medical coverage for the member of the housestaff, spouse, and minor children; (2) major medical coverage for the member of the housestaff, spouse, and minor children; and (3) group life insurance, and dismemberment and disability insurance for the member of the housestaff only. It should also be specified whether the institution will pay the full amount of premiums or only a portion of the premiums, the balance to be paid by the member of the housestaff. Co-paid benefits should be established, separately from other hospital employee benefits, as a means of maximizing benefits. In some instances, free care for the housestaff and their families at the training institutions may be provided. In lieu of insurance benefits, the contract or agreement may provide for fixed annual payments to a housestaff association for each member of the housestaff so that the housestaff association may determine and provide for insurance or other benefits for the housestaff. J. Professional Liability Insurance The contract or agreement should specify the amount of professional liability insurance that the institution will provide for each member of the housestaff together with the limits of liability applicable to such coverage. It might also be appropriate to provide in the contract or agreement that the housestaff and the institution will cooperate fully with the insurance company in the handling of any professional liability claim. K. Committee Participation Insofar as possible, the institution should agree to provide for appropriate participation by the housestaff on the various committees within the institution. This participation should be on committees concerning institutional, professional and administrative matters including grievance and disciplinary proceedings. Members should have full voting rights. Representatives of the housestaff should be selected by the members of the housestaff. L. Grievance Procedures The contract or agreement should require and publish a grievance procedure. A grievance procedure typically involves the following: (1) A definition of the term "grievance" (e.g., any dispute or controversy about the interpretation or application of the contract, any rule or regulation, or any policy or practice). (2) The timing, sequence, and end point of the grievance procedure. (3) The right to legal or other representation. (4) The right of an individual member of the housestaff or a housestaff association to initiate a grievance procedure and the obligation of the housestaff to maintain patient care during the grievance procedure. (5) A statement of the bases and procedures for the final decision on grievances (end point), and agreement of both parties to abide by the decision. (6) Should costs arise in the grievance procedure, a prior agreement as to how these costs will be apportioned between the parties. M. Disciplinary Hearings and Procedure With respect to disciplinary procedures, the provisions of Article VIII - Hearing and Appellate Review Procedure of the JCAHO Guidelines for the Formulation of Medical Staff Bylaws, Rules, and Regulations shall be applicable to the housestaff in the same manner as they are to all other members of the medical staff with the proviso that the Hearing and Appeals Committees shall contain appropriate representation of the housestaff. N. Description of the Educational Program The specific details of the operation of the educational experience should be made available to each prospective candidate. These data should include specific descriptions of training programs, including numbers of resident positions at each level of training, copies of existing housestaff contracts or agreements, approval status of programs to which candidate is applying, methods of evaluation, procedures for grievances and disciplinary action, and commitments for further training. O. Patient-Care Issues The quality of patient-care services and facilities may be specified in the contract, and could include such matters as adequate equipment, bedspace, clinical staffing, and clinical staff structuring. P. Other Provisions The agreement should provide for adequate, comfortable, safe, and sanitary facilities.

The foregoing provisions are not all-inclusive. Depending upon the institution's size, resources, location, and affiliations, if any, and also depending upon the relationship between the institution and the housestaff association, other provisions may be included, such as: (1) Maintenance of existing benefits and practices not otherwise expressly covered; (2) Housing, meals, laundry, uniforms, living-out and telephone allowances; (3) Adequate office space, facilities, and supporting services for housestaff affairs; (4) Housestaff association seminars and meetings. (BOT Rep. H, I-74; Reaffirmed: CLRPD Rep. C, A-89; Appended: Res.323, I-97; Reaffirmation A-00)